03 IncidencePreval

Principles of Epidemiology for Public Health (EPID600)
Epidemiologic measures: Incidence &

prevalence
Victor J. Schoenbach, PhD home page
Department of Epidemiology
Gillings School of Global Public Health
University of North Carolina at Chapel Hill
www.unc.edu/epid600/
1/25/2011 Incidence and prevalence 1

Famous last words
Quotations that demonstrate the value of

humility about predicting the future
(authenticity not established)
Courtesy of Suzanne Cloutier, 11/17/1998

“Louis Pasteur's theory of germs is
ridiculous fiction.”
- Pierre Pachet, Professor of Physiology at Toulouse, 1872
FAMOUS LAST WORDS: quotations that demonstrate the value of humility in predicting the future
“This `telephone´ has too many
shortcomings to be seriously considered
as a means of communication. The device
is inherently of no value to us.”
- Western Union internal memo, 1876
(Source: 2000 National Ernst & Young Entrepreneur of the
Year Awards special insert in USA Today, 2/11/2000, p9B)
“Everything that can be invented
has been invented.”
- Charles H. Duell, Commissioner, US Patent Office,1899
“The wireless music box has no imaginable
commercial value. Who would pay for a
message sent to nobody in particular?”
- David Sarnoff's associates in response to his

urgings for investment in radio in the 1920s.
“My thesis in this lecture is that
macroeconomics . . . has succeeded: Its
central problem of depression-prevention
has been solved, for all practical purposes,
and has in fact been solved for many
decades.”
- Robert E. Lucas, Jr., American Economics Association
Presidential Address, January 10, 2003
http://home.uchicago.edu/~sogrodow/homepage/paddress03.pdf
The population perspective requires
measuring disease in populations
• Science is built on classification and

measurement.
• Reality is infinitely detailed, infinitely complex.
• Classification and measurement seek to capture
the essential attributes.

Deriving meaning from stimuli
Vase or faces?
Which line is
longer?
Measurement “captures” the phenomenon
Classification and measurement are based on:

1. Objective of the classification
2. Conceptual model (understanding of the
phenomenon)
3. Availability of data (technology)

An example population (N=200)

O

 O

O
 O
 O

O
 O
How can we quantify disease in populations?

O








O




 O



O




 O
O


 OO
O




 O
O


OO

O O




 O
O


How can we quantify the frequency?
OO

O O




 O
O


Rate of occurrence of new cases
per unit time (e.g., 1 per month)
OO

O O




 O
O


1 new case in month 1

O








O




 O


1 new case in month 3, for a total of 3 cases

O




 O
O


2 new cases in month 4
 OO
O




 O
O


1 new case in month 5 (total=6)
OO

O O




 O
O


1 case in month 6
OO

O O



O

 O
O


OO

OO O



O

 O
O


2 new cases in month 8
OO

OO O



O

 OOO
O


2 cases in month 9
OO

OO O

O


O

O OOO

O


Rate of occurrence of new cases during 9 months:
1 case/month to 2 cases/month
OO

OO O

O


O

O OOO

O


Number of cases depends on length of interval
Divide by length of time interval, so can

compare across intervals
Number of new cases
Rate of new cases = –––––––––––––––––
Time interval
= 12 cases / 9 months = 1.33 cases / month

Number of cases depends on population size
So, divide by population and time:
Number of new cases

Incidence rate = ––––––––––––––––––
Population-time

How to estimate population-time?
Population at risk: the people eligible to

become a case and to be counted as one.
In this example that population declines as
each case occurs.
So estimate population-time as . . .

Population-time =
Method 1: Add up the time that each person is
at risk
Method 2: Add up the population at risk during
each time segment
Method 3: Multiply the average size of the
population at risk by the length of the time
interval
Estimating population-time - method 2
Total population-time over 9 months =
200 + 199 + 198 + 197 + 195 + 194 + 193 +
192 + 190
= 1,758 person-months
= 146.5 person-years
However, cases are not at risk for a full
month.
- better
Total population-time over 9 months =
199.5 + 198.5 + 197.5 + 196 + 194.5 + 193.5
+ 192.5 + 191 + 189
= 146 person-years
assuming that cases develop, on average, in
the middle of the month
Average size of the population at risk during the
9 months = 195.3 (1,758 / 9) or approximately:
(200 + 188) /2 = 194
Population-time = 195.3 x 9 months or
(approximately) 194 x 9 months
Equivalent to - method 3
Take initial size of population at risk and reduce
it for time the people were not at risk due to
acquiring the disease:
200 - 12/2 = 194 (approximately)
Population-time = 194 x 9 months
Incidence rate (“incidence density”)
Number of new cases

–––––––––––––––––––––––––––––––
Avg population at risk × Time interval
Number of new cases

= ––––––––––––––––––––
Population-time
What proportion of the population
at risk are affected after 5 months?

O

 O

O
 O
 O

O
 O
is affected after 1 month? (1/200)

O







is affected after 2 months? (2/200)

O




 O


is affected after 3 months? (3/200)

O




 O
O


What proportion of the population is
affected after 4 months? (5/200)
 OO
O




 O
O


6 / 200 = 0.03 = 3% = 30 / 1,000
in 5 months
 OO
O
 O



 O
O


Incidence proportion (“cumulative incidence”)
Number of new cases

5-month CI = –––––––––––––––––––
Population at risk
Incidence proportion estimates risk.

Incidence rate versus incidence proportion
• Incidence rate measures how rapidly cases are
occurring.
• Incidence proportion is cumulative.
• When care only about the “bottom line” (i.e.,
what has happened by the end of given period):
incidence proportion (CI).

• If risk period is long (e.g., cancer), we usually
observe only a portion.
• To compare results from studies with different
length of follow-up, use incidence rate (IR)
• If risk period is short, we usually observe all of it
and can use incidence proportion.

(rare disease, IR = 0.005 / month)
(see spreadsheet at epidemiolog.net/studymat/)

(common disease, IR = 0.1 / month)

Case fatality rate
“Case fatality rate” (but it’s really a proportion)

= proportion of cases who die
(in a specified time interval)
• Like a “cumulative incidence of death” in cases
[ “incidence rate of death” in cases =
“termination rate” = 1/(average survival time)]

Mortality rate
Number of deaths
Mortality rate = ––––––––––––––––––––––––––––
Population at risk × Time interval
Number of deaths
Annual mortality rate = ––––––––––––––––––––––
Mid-year population (x 1 yr)

Mortality rate (more notes)
Number of deaths
Mortality rate = ––––––––––––––––––––––––––––
Population at risk × Time interval
Number of deaths
Annual mortality rate = ––––––––––––––––––
Mid-year population
Mortality rates versus incidence rates
• Mortality data are more generally available
• Fatality reflects many factors, so mortality
rates may not be a good surrogate of incidence
rates
• Death certificate cause of death not always
accurate or useful

Prevalence – another important proportion
Number of existing (and new) cases

Prevalence = –––––––––––––––––––––––––––––––
Population at risk

1 new case, 1 death
OO

O O



O

 O
O


1 new case, 1 new death
OO

OO O



O

 O
O


2 new cases, no deaths
OO

OO O



O

 OOO
O


2 new cases, 1 new death
OO

OO O

O


O

O OOO

O


What is the prevalence? (9 / 197)
OO

OO O

O


O

O OOO

O


Fine points . . .
•Who is “at risk”?
• Endometrial cancer? Prostate cancer?
Breast cancer?
• Only women who have not had a
hysterectomy?
“Could” develop the condition + “would” be
counted.
More fine points
• Age?
• Immunity?
• Genetically susceptible?

More fine points . . .
• How do we measure time?
• Are 10 people followed for 10 years the

same as 100 people followed for 1 year?
• Aging of the cohort? Secular changes?

Fine points . . .
• Importance of stating units and scaling
unless they are clear from the context
– e.g., 120 per 100,000 person-years =
10 per 100,000 person-months
– Hazards from lack of clarity
9/22/2005, 9/8/2008 Incidence and prevalence 62

“You can never, never take anything for granted.”
Noel Hinners, vice president for flight systems at
Lockheed Martin Astronautics in Denver, concerning
the loss of the Martian Climate Orbiter due to the
Lockheed Martin spacecraft team’s having reported
measurements in English units whiles the orbiter’s
navigation team at the Jet Propulsion Laboratory
(JPL) in Pasadena, California assumed the
measurements were in metric units.

Relation of incidence and prevalence
• Prevalence depends on incidence

• Higher incidence leads to higher prevalence if duration
of cases does not change.
• Limitation of the bathtub analogy – flow rate needs to
be expressed relative to the size of the source
• Introducing a new analogy . . .

Existing
cases
Population
at risk
Deaths,
cures, etc.
Incidence, prevalence, duration of hospitalization
Remote community of 101,000 people
One hospital, patient census = 1,000
Steady state
500 admissions per week
Prevalence = 1,000/101,000 = 9.9/1,000
IR = 500/100,000 = 5/1,000/week
Duration Prevalence / IR = 2 weeks
Relation of incidence and prevalence
Under somewhat special conditions,

Prevalence odds = incidence × duration
Prevalence incidence × duration
(see spreadsheet at www.epidemiolog.net/studymat/)

Standardization
• When objective is comparability, need to adjust
for different distributions of other determinants
• Strategy:
• Analyze within each subgroup (stratum)
• Take a weighted average across strata
• Use same weights for all populations
(See the Evolving Text on www.epidemiolog.net)
Familiar example of weighted averages
• Liters of petrol per kilometer - differs for Interstate
(0.050 LpK) and non-Interstate (0.100 LpK) driving.
• To compare different cars, can:
• Compare them for each type of driving separately
(stratified analysis)
• Average for each car, using one set of weights
(e.g., 80% Interstate, 20% non-Interstate)
• E.g. = 0.80 x 0.050 LpK + 0.20 x 0.100 LpK = 0.060 LpK
Comparing a Suburu and a Mazda
Juan drives a Suburu 800 km on Interstate highways
and 200 km on other roads. His car uses 0.050 LpK
on Interstates and 0.100 LpK on other roads, for a
total of 60 liters of petrol, an average of 0.060 LpK
(60 L / 1000 km). His overall LpK can be expressed
as a weighted average:
(800/1000) x 0.050 LpK + (200/1000) x 0.100 LpK
= 0.80 x 0.050 LpK + 0.20 x 0.100 LpK = 0.060 LpK
Shizu drives her Mazda on a different route, with
only 200 km on Interstate and 800 km on other
roads. She uses 0.045 lpk on Interstate highways
and 0.080 LpK on non-Interstate. She uses a total
of 73 liters, or 0.073 LpK. Her overall LpK can be
expressed as a weighted average:
(200/1,000) x 0.045 LpK + (800/1,000) x 0.080 LpK
= 0.20 x 0.045 LpK + 0.80 x 0.080 LpK =0.073 LpK
How can we compare their fuel efficiency?
Juan Shizu
Km LpK Km LpK
Interstate 800 0.050 200 0.045
Other 200 0.100 800 0.080
Total 1,000 0.060 1,000 0.073

Total fuel efficiency is not comparable
because weights are different
Juan Shizu
% LpK % LpK
Interstate 80 0.050 20 0.045
Other 20 0.100 80 0.080
Total 100% 0.060 100% 0.073

By adopting a “standard” set of weights we
can compare fairly
Juan Shizu
% LpK % LpK
Interstate 60 0.050 60 0.045
Other 40 0.100 40 0.080
Total 100 0.060 100 0.073
Standardized 0.070 0.059

•Juan’s Suburu:
= 0.60 x 0.050 LpK + 0.40 x 0.100 LpK =0.070 LpK
•Shizu’s Mazda:
= 0.60 x 0.045 LpK + 0.40 x 0.080 LpK =0.059 LpK
The choice of weights may often affect the results of

the comparison.

“I'm just glad it'll be Clark Gable who's
falling on his face and not Gary Cooper.”
- Gary Cooper on his decision not to take the

leading role in “Gone With The Wind”
“A cookie store is a bad idea.
Besides, the market research reports
say America likes crispy cookies,
not soft and chewy cookies like you make.”
- Response to Debbi Fields' idea of starting

Mrs. Fields' Cookies.
“Computers in the future may weigh
no more than 1.5 tons.”
- Popular Mechanics, forecasting the

relentless march of science, 1949
“I think there is a world market
for maybe five computers.”
-Thomas Watson, chairman of IBM, 1943

03 IncidencePreval

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03 IncidencePreval

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Principles of Epidemiology for Public Health (EPID600)

Epidemiologic measures: Incidence &

Victor J. Schoenbach, PhD home page

1/25/2011 Incidence and prevalence 1

Quotations that demonstrate the value of

Courtesy of Suzanne Cloutier, 11/17/1998

5/20/2002 Incidence and prevalence 2

- Pierre Pachet, Professor of Physiology at Toulouse, 1872

- Charles H. Duell, Commissioner, US Patent Office,1899

- David Sarnoff's associates in response to his

• Science is built on classification and

1/25/2011 Incidence and prevalence 8

Classification and measurement are based on:

1/25/2011 Incidence and prevalence 10

Divide by length of time interval, so can

= 12 cases / 9 months = 1.33 cases / month

1/9/2007 Incidence and prevalence 29

So, divide by population and time:

Number of new cases

1/25/2011 Incidence and prevalence 30

Population at risk: the people eligible to

1/25/2011 Incidence and prevalence 31

Number of new cases

Number of new cases

Number of new cases

1/25/2011 Incidence and prevalence 44

1/25/2011 Incidence and prevalence 45

1/25/2011 Incidence and prevalence 46

(see spreadsheet at epidemiolog.net/studymat/)

2/7/2012 Incidence and prevalence 48

“Case fatality rate” (but it’s really a proportion)

5/20/2002 Incidence and prevalence 49

1/30/2007 Incidence and prevalence 50

5/20/2002 Incidence and prevalence 52

Number of existing (and new) cases

1/9/2007 Incidence and prevalence 53

5/20/2002 Incidence and prevalence 60

• How do we measure time?

• Are 10 people followed for 10 years the

• Aging of the cohort? Secular changes?

5/20/2002 Incidence and prevalence 61

9/22/2005, 9/8/2008 Incidence and prevalence 62

1/30/2004 Incidence and prevalence 63

• Prevalence depends on incidence

5/20/2002 Incidence and prevalence 64

Under somewhat special conditions,

1/25/2011 Incidence and prevalence 68

8/17/2009 Incidence and prevalence 73

8/17/2009 Incidence and prevalence 74

8/17/2009 Incidence and prevalence 75

The choice of weights may often affect the results of

8/17/2009 Incidence and prevalence 76

- Gary Cooper on his decision not to take the

- Response to Debbi Fields' idea of starting

- Popular Mechanics, forecasting the

-Thomas Watson, chairman of IBM, 1943

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